Vaginal dryness: a review of current understanding and management strategies.

The issue of vaginal dryness in genitourinary syndrome of menopause (GSM) and its pervasive impact on women's quality of life is often overlooked. Extensive surveys conducted worldwide reveal limited understanding of vaginal dryness among public and health-care providers. Physician knowledge on menopause medicine varies globally, highlighting the need for standardized training. Effective communication between physicians and patients plays a crucial role in diagnosing and treating GSM symptoms. There are multiple treatment options to improve vaginal lubrication, including hormonal and non-hormonal therapies, along with lifestyle modifications. Tailoring treatments to individual patient preferences is crucial for compliance. Overall, GSM is multifaceted, from the prevalence of vaginal dryness to the nuances of treatment preferences. The urgency of widespread education and awareness of this matter must be underscored to meet the aim of enhancing the well-being and quality of life for women.

Characteristics of patients with tuberculosis and the associated factors with TB-related mortality in a rural setting in Sarawak, Malaysia: A single-centre study.

INTRODUCTION: Tuberculosis (TB) in Malaysia has estimated incidence and mortality rates of 81 cases per 100,000 people-year and 4.9 per 100,000 populations, respectively. This study aimed to study the characteristics of rural TB patients and their mortality outcomes. MATERIALS AND METHODS: This is a retrospective observational study involving real-world data analysis, looking into TB patients in Lubok Antu Health Clinic by obtaining data through clinic cards, from 1 January 2019 till 31 December 2020. Statistical significance was p < 0.05. RESULTS: Eighty-four patients were included. Fifty-two (61.9%) were male. Median age was 58.5 (39-67). Forty-six (54.8%) had smear-positive TB. Seventy-eight (92.9%) were alive at treatment completion. Fifteen (17.9%) experienced adverse drug reactions. Estimated prevalence and mortality rate were 7.1% and 10.7 per 100,000 populations, respectively. Regression analyses revealed that drug reaction was significantly associated with compliance [OR = 8.38 (95% CI: 1.26, 55.53), p = 0.029]. Patients compliant with treatment were more likely to survive [OR = 12.5 (95% CI: 1.61, 97.34), p = 0.028]. CONCLUSION: Compliance with TB treatment should be emphasised to reduce TB-related mortality.

Management of patent foramen ovale in embolic stroke of undetermined source patients: Malaysian experts' consensus.

INTRODUCTION: About 20 to 40% of ischaemic stroke causes are cryptogenic. Embolic stroke of undetermined source (ESUS) is a subtype of cryptogenic stroke which is diagnosed based on specific criteria. Even though patent foramen ovale (PFO) is linked with the risk of stroke, it is found in about 25% of the general population, so it might be an innocent bystander. The best way to treat ESUS patients with PFO is still up for discussion. MATERIALS AND METHODS: Therefore, based on current evidence and expert opinion, Malaysian expert panels from various disciplines have gathered to discuss the management of ESUS patients with PFO. This consensus sought to educate Malaysian healthcare professionals to diagnose and manage PFO in ESUS patients based on local resources and facilities. RESULTS: Based on consensus, the Malaysian expert recommended PFO closure for embolic stroke patients who were younger than 60, had high RoPE scores and did not require long-term anticoagulation. However, the decision should be made after other mechanisms of stroke have been ruled out via thorough investigation and multidisciplinary evaluation. The PFO screening should be made using readily available imaging modalities, ideally contrasttransthoracic echocardiogram (c-TTE) or contrasttranscranial Doppler (c-TCD). The contrast-transesophageal echocardiogram (c-TEE) should be used for the confirmation of PFO diagnosis. The experts advised closing PFO as early as possible because there is limited evidence for late closure. For the post-closure follow-up management, dual antiplatelet therapy (DAPT) for one to three months, followed by single antiplatelet therapy (APT) for six months, is advised. Nonetheless, with joint care from a cardiologist and a neurologist, the multidisciplinary team will decide on the continuation of therapy.

Intravenous thrombolysis for multi-ethnic Asians with acute ischaemia stroke in Malaysian public primary stroke centres versus acute stroke ready hospitals: Comparison of real-world clinical outcomes.

INTRODUCTION: Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator is beneficial in acute ischaemic stroke (AIS). We aim to compare the realworld clinical outcomes and service efficiency of IVT in Malaysian primary stroke centres (PSCs) versus acute stroke ready hospitals (ASRHs). MATERIALS AND METHODS: We conducted a multi-centre cohort study involving 5 PSCs and 7 ASRHs in Malaysia. Through review of medical records of AIS patients who received IVT from 01 January 2014 to 30 June 2021, real-world data was extracted for analysis. Univariate and multivariate regression models were employed to evaluate the role of PSCs versus ASRHs in post-IVT outcomes and complications. Statistical significance was set at p<0.05. RESULTS: A total of 313 multi-ethnic Asians, namely 231 from PSCs and 82 from ASRHs, were included. Both groups were comparable in baseline demographic, clinical, and stroke characteristics. The efficiency of IVT delivery (door-toneedle time), functional outcomes (mRS at 3 months post- IVT), and rates of adverse events (intracranial haemorrhages and mortality) following IVT were comparable between the 2 groups. Notably, 46.8% and 48.8% of patients in PSCs and ASRHs group respectively (p=0.752) achieved favourable functional outcome (mRS≤1 at 3 months post-IVT). Regression analyses demonstrated that post-IVT functional outcomes and adverse events were independent of the role of PSCs or ASRHs. CONCLUSION: Our study provides real-world evidence which suggests that IVT can be equally safe, effective, and efficiently delivered in ASRHs. This may encourage the establishment of more ASRHs to extend the benefits of IVT to a greater proportion of stroke populations and enhance the regional stroke care.

Clinical outcomes of acute stroke thrombolysis in neurologist and non-neurologist centres - A comparative study in Malaysia.

BACKGROUND: Thrombolytic therapy with intravenous alteplase is a well-established treatment for acute ischaemic stroke (AIS). However, in Malaysia, treatment prescription is often limited by the availability of neurologists. The objective was to compare the outcomes of acute stroke thrombolysis therapy prescribed by neurologists in the Seberang Jaya Hospital (SJH) and non-neurologists in the Taiping Hospital (TH). METHODS: In this cross-sectional study, all AIS patients who received thrombolytic therapy in SJH and TH between January 2012 and September 2019 were included. Clinical data was extracted from admission records. The outcomes assessed were the percentage of patients who achieved excellent functional outcome at 3 months (modified Rankin scale of 0 to 1), rates of symptomatic intracranial haemorrhage (SICH), and mortality. RESULTS: A total of 63 AIS patients who received thrombolytic therapy were included, of which 37 patients (58.7%) were treated in SJH. The median NIHSS on admission was 12 in SJH and 11.5 in TH. In all 21.6% of patients from SJH and 30.7% of patients from TH achieved favourable functional outcome at 3 months (p=0.412). There were no significant differences between the two centres in terms of the rates of SICH (10.8% in SJH and 3.8% in TH, p=0.314) and 3-month mortality (24.3% versus 12.5%, p=0.203). CONCLUSION: The 3-month functional outcomes and complication rates of stroke thrombolysis in hospitals with or without neurologists are not significantly different. Thus non-neurologist hospitals may be able to provide thrombolysis service to AIS patients safely and effectively.

A Review of Stroke Research in Malaysia from 2000 - 2014.

Over 100 articles related to stroke were found in a search through a database dedicated to indexing all literature with original data involving the Malaysian population between years 2000 and 2014. Stroke is emerging as a major public health problem. The development of the National Stroke Registry in the year 2009 aims to coordinate and improve stroke care, as well as to generate more data on various aspects of stroke in the country. Studies on predictors of survival after strokes have shown potential to improve the overall management of stroke, both during acute event and long term care. Stroke units were shown to be effective locally in stroke outcomes and prevention of stroke-related complications. The limited data looking at direct cost of stroke management suggests that the health economic burden in stroke management may be even higher. Innovative rehabilitation programmes including braincomputer interface technology were studied with encouraging results. Studies in traditional complementary medicine for strokes such as acupuncture, Urut Melayu and herbal medicine were still limited.

National Stroke Registry (NSR): Terengganu and Seberang Jaya experience.

The National Stroke Registry (NSR) was established in 2009 under National Neurology Registry (NNeuR) . The main objectives of NSR were to describe the demographic and disease pattern of stroke patients in Malaysia, to examine the risk factors and evaluate the specified treatment and outcomes. This prospective observational study was carried out from August 2009 until December 2010 using a standardized case report form which involved two participating hospital, namely Hospital Sultanah Nur Zahirah, Kuala Terengganu and Hospital Seberang Jaya, Pulau Pinang. There were 1018 patients registered. Ischemic stroke accounted for the majority of cases (73.3%). The most common risk factor was hypertension (75.5 %), followed by diabetes mellitus, previous stroke or Transient Ischemic Attack (TIA), hyperlipidemia and active smoker: 45.6%, 25.1%, 22.4%, and 19.4%, respectively. Overall, our stroke management, based on nine stroke key performance indicators (KPI) still needs to be improved. There was a total of 121 mortality cases with the main contributing factor was massive cerebral bleed (21.6%). In conclusion, the findings highlight the important of primary and secondary stroke management. Further and continuous observation with more site date provider (SDP) involvement is needed to get a more comprehensive data on stroke in Malaysia.

Rising from the dead!

A report of a patient with Lazarus phenomenon (the return of spontaneous circulation after cardiopulmonary resuscitation) following cardiac arrest (myocardium ischemia) is presented. A 65 year patient was found unconscious at home. He taken to the emergency department On arrival he was unconscious, his pupils fixed and dilated bilaterally. Resuscitation proceeded for 55 minutes. He was then pronounced dead. Forty minutes later spontaneous breathing was noted and his blood pressure was 110/48 and heart rate 90bpm. He survived a further 13 days in the coronary care unit. The implications for management of cardiac arrest in the emergency and medical department are discussed.

Antiplatelet therapy in diabetic ischemic stroke patients: associated factors and outcomes.

BACKGROUND: Patients with diabetes mellitus (DM) are more prone to develop atherosclerotic complications including stroke. Moreover, as a primary and secondary prevention of stroke, antiplatelet therapy is recommended by clinical guidelines for patients with DM. AIMS: This study aimed to determine the prevalence of antiplatelet therapy use prior to current stroke in diabetic ischemic stroke patients, to examine the factors associated with the use of this important therapy and to assess the impact of the previous use of antiplatelet therapy on ischemic stroke outcomes. METHODS: An observational study of diabetic acute ischemic stroke patients attending a Malaysian hospital during a 1-year period was carried out. Demographic information, risk factors, previous antiplatelet use and variables used to assess stroke outcomes were collected from medical records. RESULTS: Overall, 295 diabetic stroke patients were analyzed. The prevalence of previous antiplatelet use among diabetic patients was 38.3%. The independent variables associated with the previous use of antiplatelet medication were previous stroke attack (p < 0.001) and ischemic heart disease (p < 0.001). Better outcomes as measured by a minor Glasgow Coma Scale at admission (p = 0.032), and a higher Modified Barthel index at discharge (p = 0.027) were observed among patients on previous antiplatelet therapy. CONCLUSION: Our data suggest that antiplatelet therapy is under prescribed among such diabetic stroke patients, particularly in primary prevention. Effective methods to increase antiplatelet use and to enhance the adherence of clinical practice guidelines should be considered at the national and community level.

Ischemic Stroke in a Young Patient with Nephrotic Syndrome and Antiphospholipid Syndrome.

We report a case of a 21-year-old man with underlying nephrotic syndrome (NS) secondary to minimal change disease, who developed an ischemic stroke with left hemiparesis. He received intravenous thrombolysis followed by a mechanical thrombectomy. After mechanical thrombectomy, he developed acute kidney injury which subsequently required haemodialysis. Further workup revealed that he had concomitant antiphospholipid syndrome (APS) and NS. He was started on vitamin K antagonist anticoagulant. This case report illustrates the importance of workup in identifying causes of ischemic stroke in a young patient.

Optimal Scree-CNN for Detecting NS1 Molecular Fingerprint from Salivary SERS Spectra.

Dengue fever (DF) is a viral infection with possible fatal consequence. NS1 is a recent antigen based biomarker for dengue fever (DF), as an alternative to current serum and antibody based biomarkers. Convolutional Neural Network (CNN) has demonstrated impressive performance in machine learning problems. Our previous research has captured NS1 molecular fingerprint in saliva using Surface Enhanced Raman Spectroscopy (SERS) with great potential as an early, noninvasive detection method. SERS is an enhanced variant of Raman spectroscopy, with extremely high amplification that enables spectra of low concentration matter, such as NS1 in saliva, readable. The spectrum contains 1801 features per sample, at a total of 284 samples. Principal Component Analysis (PCA) transforms high dimensional correlated signal to a lower dimension uncorrelated principal components (PCs), at no sacrifice of the original signal content. This paper aims to unravel an optimal Scree-CNN model for classification of salivary NS1 SERS spectra. Performances of a total of 490 classifier models were examined and compared in terms of performance indicators [accuracy, sensitivity, specificity, precision, kappa] against a WHO recommended clinical standard test for DF, enzyme-linked immunosorbent assay (ELISA). Effects of CNN parameters on performances of the classifier models were also observed. Results showed that Scree-CNN classifier model with learning rate of 0.01, mini-batch size of 64 and validation frequency of 50, reported an across-the-board 100% for all performance indicators.

Neuroacanthocytosis: a rare inherited movement disorder.

The chorea-acanthocytosis syndrome (CHAC) is a rare disorder beginning in late adolescent or adult life in association with acanthocytosis, a normal lipid profile and characterized by progressive neurological disease. The inheritance is usually autosomal recessive, although apparent sporadic and autosomal dominant instances are also known. We report here a young man who presented with choreo-athetoid movement, dystonia, tics, symmetrical axonal polyneuropathy with normal cognitive function. The subsequent peripheral blood film reveals acanthocytes > 5%. Diagnosis of neuroacanthocytosis was made.

Anaesthetists' nightmare: masseter spasm after induction in an undiagnosed case of myotonia congenita.

We report an undiagnosed case of myotonia congenita in a 24-year-old previously healthy primigravida, who developed life threatening masseter spasm following a standard dose of intravenous suxamethonium for induction of anaesthesia. Neither the patient nor the anaesthetist was aware of the diagnosis before this potentially lethal complication occurred.

PCA-MLP SVM distinction of salivary Raman spectra of dengue fever infection.

Dengue fever (DF) is a disease of major concern caused by flavivirus infection. Delayed diagnosis leads to severe stages, which could be deadly. Of recent, non-structural protein (NS1) has been acknowledged as a biomarker, alternative to immunoglobulins for early detection of dengue in blood. Further, non-invasive detection of NS1 in saliva makes the approach more appealing. However, since its concentration in saliva is less than blood, a sensitive and specific technique, Surface Enhanced Raman Spectroscopy (SERS), is employed. Our work here intends to define an optimal PCA-SVM (Principal Component Analysis-Support Vector Machine) with Multilayer Layer Perceptron (MLP) kernel model to distinct between positive and negative NS1 infected samples from salivary SERS spectra, which, to the best of our knowledge, has never been explored. Salivary samples of DF positive and negative subjects were collected, pre-processed and analyzed. PCA and SVM classifier were then used to differentiate the SERS analyzed spectra. Since performance of the model depends on the PCA criterion and MLP parameters, both are examined in tandem. Its performance is also compared to our previous works on simulated NS1 salivary samples. It is found that the best PCA-SVM (MLP) model can be defined by 95 PCs from CPV criterion with P1 and P2 values of 0.01 and -0.2 respectively. A classification performance of [76.88%, 85.92%, 67.83%] is achieved.

A study on community acquired pneumonia in adults requiring hospital admission in Penang.

A study was carried out to determine the pattern of microbiological organisms causing community acquired pneumonia in adult patients admitted to Penang Hospital between November 1999 and August 2000. Altogether, 98 patients (64 males, 34 females) with a mean age (+/- S.D.) of 55.9 (+/- 19.0) (range 15 to 87) years were included in the study. Causative organisms were identified in 42 patients (42.9%). Mycobacterium tuberculosis was the commonest pathogen being identified in 15.3% of cases, followed by Klebsiella pneumoniae (7.2%), Pseudomonas aeruginosa (6.1%) and Staphylococcus aureus (5.1%). Streptococcus pneumoniae and Acinetobacter spp accounted for 3 cases each (3.1%) and Haemophilus influenzae, non-haemolytic Streptococcus, Mycoplasma pneumoniae, Salmonella typhi, Escherichia coli, Klebsiella spp and Pseudomonas spp for 1 case each (1.0%). Four patients (4.1%) had dual infections and no case of legionella pneumonia was found in this series.